Suicide: Establishing The Risk

Approximately 340,000 people kill themselves every year in this country. If we include all those others who kill themselves purposely but in a way that seems to be accidental, such as an automobile crash, the number would be higher. Suicide is a major public health problem. To some extent, it is contagious. The rate of suicide spikes immediately following a report of a celebrity suicide. Proper medical and psychiatric care cannot eliminate suicides. A successful suicide is not a sign that someone, a psychiatrist or a family member, has been derelict. It is a common complication of a number of psychiatric illnesses, especially depression.

Depression in one form or another is probably the most common cause for referral to a psychiatrist. A major depression is thought to affect twenty percent of the population at some point in their lives. And most people who are prone to a depression become depressed a second and third time. On each occasion, the affected person is vulnerable to a suicide attempt even if that person has responded well to medication in the past, and knows that. The condition may engender each time a desperation that overwhelms all rational considerations and blots out all expectations of life being worth living.

Probably most truly depressed persons think from time to time that it might be just as well if they did not wake up the next day. This is not so much a suicidal idea as it is a thought about death—oblivion– a place where all their bad feelings will go away. Only somewhat less common, perhaps, are vague, fleeting thoughts of actually committing suicide. This rumination is described in psychiatric jargon as “suicidal ideation,” often written into medicals records with the caveat, “but no intent.” Still others, more profoundly depressed and more importantly, hopeless, will make an actual attempt. It is said that for every successful suicide, ten others have made an attempt; and for every attempted suicide, ten others have thought of killing themselves.

Most people who are depressed are not actively suicidal; but anyone who is depressed can become suicidal. The best way of preventing such a calamity is to keep the possibility of suicide in mind. Families, in particular, have to remember that anyone who is depressed can suddenly try to do themselves harm. Suicide in general cannot be eliminated, but particular suicides often give warning; and these can be prevented. The extra ingredient that makes a depressed person actively suicidal is hopelessness.

Determining risk: It often falls to a psychiatrist to judge whether someone is suicidal. A depressed person comes to a psychiatric office, or to an emergency room, with an obvious depression. Such a person could be profoundly depressed and still not be suicidal; and others who are seemingly not very depressed, are nevertheless hanging on by a thread. I have seen patients make suicide attempts because someone has spoken to them harshly or refused them an extra dessert.

Simply taking a history will often give hints of the danger of suicide. People who have no family and no friends are more vulnerable. Someone who is religious or who has some overriding purpose—meaningful work, for instance– is less likely to commit suicide even when depressed.

At some point, the psychiatrist will ask the patients directly whether or not they are thinking of killing themselves. Bringing up the subject is not an embarrassment. And someone not already inclined to injure himself will not do it because someone else suggested the idea to him. Besides, the thought of death and suicide is commonplace among depressed people, if not universal. I have mentioned the phrase, “suicidal ideation, but no intent;” but intent is variable and hard to judge. If a patient says “I’ve been thinking of suicide, but I think about the effect it would have on my children,” or “I know it is morally wrong,” I am much less concerned than I would be if the patient told me he had a gun, which he just checked out to see if it was in working condition, or, if she told me, “I counted the pills. I have 48 tranquilizers and another ten pain pills.” The first two patients would seem to me less likely to kill themselves, and the second two more likely. There are usually a number of factors pushing a depressed person towards suicide, and a number of factors pushing the other way. Sometimes, when the patient has the obvious vegetative signs of a major depression– early –morning awakening, for example– I can be pretty sure anti-depressants will work. Therefore, I may ask the patient to commit to staying alive for 3 to 4 weeks—to give the drugs time to work.

Suicidal risk may be difficult to determine if there has not been an active attempt; but it a judgment that has to be made. If a patient who comes into an emergency room is thought to be actively suicidal, he will be admitted. If not, the patient will often be returned home with a referral to a psychiatrist.

Sometimes a suicide attempt is intended to serve some other purpose

The Suicide Gesture is an act which seems to represent a desire to commit suicide, but which is really designed to make a point. It is an attempt to influence somebody.

When I was a psychiatric resident on call to an emergency room, a woman was referred to me by another doctor who had bandaged her wrists.

“Why did you cut your wrists?” I asked her.

“Because nobody was paying attention to me during dinner. I want you to tell my husband that if he doesn’t take me on vacation, I’m going to kill myself.”

Usually, when someone wants to use the threat of suicide to manipulate somebody, it is not so explicit. This woman obviously had no intention of killing herself. But suicide gestures should not be ignored. First of all, such a person may succeed inadvertently in causing an injury. It is not so easy for someone who slashes her wrists for effect to avoid cutting a nerve. I saw a suicide note written by a woman who was mad at her boyfriend. She had taken a combination of a narcotic and a number of tranquilizers. Obviously, she did not realize how lethal that combination could be. The note that she was writing when she died described her plans for the following summer. She had not really intended to kill herself, but that is what she did.

Secondly, a suicide gesture may very well precede a later, more serious, attempt. Most successful suicides follow a history of previous attempts.

Third, obviously, whoever has to get her way by behaving in such an inappropriate manner has few emotional resources, and should be in therapy.

Following an actual suicide attempt: Often a psychiatrist will see a patient for the first time following a suicide attempt. The same decision has to be made. Was that attempt reflective of an unequivocal desire to kill oneself, or did it express some ambivalence? There are a number of people who make a suicide attempt, but then change their minds. They may take a bunch of pills and then tell someone what they did, with the expectation that they will be brought to an emergency room to have their stomachs pumped out or be rescued in some other way. Others may slash their wrists and then go on their own initiative to a hospital to be stitched up. A psychiatrist seeing such a patient may or may not be inclined to recommend hospitalization. If the attempt had the potential to be lethal, hospitalization is more likely. Making a suicide attempt in a place where there is a reasonable expectation that no one will know of it, is one such example. Going to a motel to kill oneself is more serious than the same act undertaken in one’s bedroom.

Certain methods of suicide are inherently more lethal than others. A gun, the preferred method of men, is inherently more dangerous (although, surprisingly, not always fatal) than taking pills. For that reason, more men successfully kill themselves, even though more women make the attempt. Whether or not to hospitalize is a decision that rests finally with the psychiatrist, consulting with the patient’s family. The patient’s wishes are secondary to the need to protect him. But hospitalization is not always the best thing, or the safest thing, to do. In my next post I will discuss hospitalization as a device to prevent suicide.